Ultrasound B-scans in the follow-up of head and neck tumors

Guidelines for the Surgical Management of Oral Cancer: Korean Society of Thyroid-Head and Neck Surgery

Korean Society of Thyroid-Head and Neck Surgery appointed a Task Force to provide guidance on the implementation of a surgical treatment of oral cancer. MEDLINE databases were searched for articles on subjects related to “surgical management of oral cancer” published in English. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. The quality of evidence was rated with use RoBANS (Risk of Bias Assessment Tool for Nonrandomized Studies) and AMSTAR (A Measurement Tool to Assess the Methodological Quality of Systematic Reviews). Evidence-based recommendations for practice were ranked according to the American College of Physicians grading system. Additional directives are provided as expert opinions and Delphi questionnaire when insufficient evidence existed. The Committee developed 68 evidence-based recommendations in 34 categories intended to assist clinicians and patients and counselors, and health policy-makers. Proper surgical treatment selection for oral cancer, which is directed by patient- and subsite-specific factors, remains the greatest predictor of successful treatment outcomes. These guidelines are intended for use in conjunction with the individual patient’s treatment goals.

Guidelines for the Surgical Management of Laryngeal Cancer: Korean Society of Thyroid-Head and Neck Surgery

Korean Society of Thyroid-Head and Neck Surgery appointed a Task Force to develop clinical practice guidelines for the surgical treatment of laryngeal cancer. This Task Force conducted a systematic search of the EMBASE, MEDLINE, Cochrane Library, and KoreaMed databases to identify relevant articles, using search terms selected according to the key questions. Evidence-based recommendations were then created on the basis of these articles. An external expert review and Delphi questionnaire were applied to reach consensus regarding the recommendations. The resulting guidelines focus on the surgical treatment of laryngeal cancer with the assumption that surgery is the selected treatment modality after a multidisciplinary discussion in any context. These guidelines do not, therefore, address non-surgical treatment such as radiation therapy or chemotherapy. The committee developed 62 evidence-based recommendations in 32 categories intended to assist clinicians during management of patients with laryngeal cancer and patients with laryngeal cancer, and counselors and health policy-makers.

Sonographic examination of the neck after definitive radiotherapy for node-positive oropharyngeal cancer

BACKGROUND AND PURPOSE

Radiographic determination of viable disease in cervical adenopathy following RT for head and neck cancer can be challenging. The purpose of this study was to evaluate the utility of US, with or without FNA, in regard to the postradiotherapy effects on documented metastatic adenopathy in patients with oropharyngeal cancer.

MATERIALS AND METHODS

This study included 133 patients with node-positive oropharyngeal cancer who were irradiated from 1998 to 2004. Sonographic evaluation was performed within 6 months of completion of radiation. Posttreatment US results were compared with pretreatment CT images and were recorded as the following: progression, suspicious, indeterminate, posttreatment change, or regression (positive) versus nonsuspicious or benign (negative). FNAC was classified as nondiagnostic, negative, indeterminate, or positive. Results of US and US-guided FNAC were correlated with findings at neck dissection and disease outcome.

RESULTS

Of 203 sonographic examinations, 90% were technically feasible and yielded a nonequivocal imaging diagnosis. Of 87 US-guided FNAs, 71% yielded a nonequivocal tissue diagnosis. The PPV and NPV of initial posttreatment US were 11% and 97%. Sensitivity and specificity were 92% and 28%. The PPV and NPV of US-guided FNA were 33% and 95%, and the sensitivity and specificity were 75% and 74%. On serial sonographic surveillance, of 33 patients with nonsuspicious findings, only 1 (3%) had neck recurrence. Of 22 patients with questionable findings on CT and negative findings on US, none had a neck recurrence.

CONCLUSIONS

In experienced hands, serial US is an inexpensive noninvasive reassuring follow-up strategy after definitive head and neck RT, even when CT findings are equivocal.

What the clinician wants to know: surgical perspective and ultrasound for lymph node imaging of the neck

Imaging of lymph node metastases in the neck can have two major indications: (1) prognosis and assisting with choice of treatment; (2) staging and detection of clinically occult metastases in different levels of the neck. Both indications are discussed. The role and limitations of US and US-guided fine-needle aspiration cytology are also reviewed.

Ultrasound of the neck

Sonography, when performed by an experienced examiner, can be used for evaluation of many pathologies in the head and neck area. Some benign neck lesions, such as cysts, lipomas, carotid body tumors, and hyperplastic lymph nodes, have typical sonomorphology. Sonography has an accuracy rate of about 90% in cervical lymph node staging and can delineate subclinical lymph node recurrences. It is the method of choice for evaluation of tumor infiltrations of the wall of the great vessels. Salivary gland tumors in the superficial lobe can be delineated completely by sonography. Salivary stones can be detected and localized. Carcinoma of the tongue and floor of the mouth with T1 and T2 staging can be assessed by US. The use and contribution of color Doppler sonography for the assessment of pathologic entities in the neck is a method under clinical investigation. US-guided fine-needle aspiration biopsy of lymph nodes and tumors of the salivary glands is easy to perform and is characterized by high sensitivity and specificity. To perform US examinations of the head and neck area of the highest quality the examiner should be familiar with the anatomy of the head and neck, be informed about the clinical problem, and have experience in the interpretation of abnormal US findings. US of the head and neck area is one of the most difficult sonographic examinations and should be performed by an experienced physician.

Radiologic evaluation of neck metastases: the otolaryngologist's perspective

Imaging of the neck for the assessment of nodal metastases can be used to detect occult metastases or to assess operability of palpable metastases. The detection of small occult metastases has limitations, as micrometastases cannot be depicted. However, imaging can diminish the risk of occult metastases and thus influence management; for this purpose a very sensitive technique is necessary. The currently used radiologic criteria are not sensitive enough to accomplish enough reduction in the risk of occult metastases. Therefore, more sensitive CT and MRI criteria, but especially ultrasound guided aspiration, should be used to assess the clinically negative neck.

Diagnostic evaluation of the neck

Modern imaging for neck node metastases has increased our ability to predict the presence of palpably occult metastases and predict the resectability of large metastases. The accuracy of CT scans, MR imaging, but especially US-FNAC, has increased to such an extent that clinical consequences are being attached to negative radiologic findings in a clinically N0 neck. As not all palpably occult metastases can be detected, especially when they are micrometers, follow-up should be strict, with use of US-FNAC in the neck observed instead of treated electively.

Ultrasonographic evaluation of small cervical lymph nodes in head and neck cancer

To establish sonographic criteria for differentiating metastasis and nonmetastasis in small cervical lymph nodes, correlations between sonographic parameters and histological diagnosis were statistically examined in 117 lymph nodes with maximal diameter of up to 10 mm in the sonographic findings, consisting of 26 metastatic and 91 nonmetastatic nodes. The equations obtained with logistic regression analysis showed lambda predictive values of -1.5 and 0.5 as effective cutoff-point criteria, and were considered to be a reliable indicator for differentiating small nodes with predictive values outside of -1.5 < lambda < 0.5. The sensitivity, specificity and accuracy with predictive values outside of -1.5 < lambda < 0.5 were 83%, 97% and 95%, respectively.

Comparison of ultrasound-fine needle aspiration and computed tomography in patients undergoing elective neck dissection

BACKGROUND

Ultrasound of the neck with fine needle aspiration (US-FNA) of suspicious lymph nodes has potential advantages over other radiologic techniques as a screening method for the NO neck in head and neck cancer.

METHODS

Twenty-five patients with head and neck cancer who underwent both US of the neck with FNA of any suspicious lymph nodes and neck computed tomography (CT) prior to elective neck dissection were studied. The majority of patients had squamous cell carcinoma (SCC) of the upper aerodigestive tract. Histopathologic results of the neck specimens were compared with each screening technique (palpation, US, US-FNA, CT).

RESULTS

Computed tomography (87.9%) and US-FNA (84.9%) had similar overall accuracy in terms of screening the NO neck in our study and were superior to palpation (69.7%) and US alone (72.7%). Specificity was 100% for both CT and US-FNA, with a sensitivity of 60% for CT and 50% for US-FNA. Ultrasound-FNA and CT showed false-negative examinations on virtually the same cases.

CONCLUSIONS

Overall, US-FNA was comparable to CT in screening the NO neck in our study. The choice of which modality to employ for imaging the clinically negative neck depends on a number of factors, including the location and clinical extent of the primary tumor as well as the experience and preference of the head and neck surgeon and radiologist.

Palpation compared with ultrasound in the assessment of malignant cervical lymph nodes

This prospective study compares the results of pre-operative clinical examination and simple ultrasound examination of the neck in 18 patients with proven head and neck primary tumours and palpable cervical lymphadenopathy, who then underwent 21 radical neck dissections. Neck palpation and ultrasound examination were compared with histological examination. Ultrasound did not add significantly to the information obtainable by simple neck palpation in this group of patients.

Metastatic carcinoma in the neck: a clinical computerized tomography scan and ultrasound study

Metastatic cervical lymph node involvement is a major determinant of treatment planning and prognosis of upper aerodigestive tract tumours. If the metastatic tumor invades the carotid artery wall then complete tumour excision is not possible unless carotid artery ligation or replacement is planned. A prospective study was performed to assess the role of palpation, computerized tomography (CT) and B-mode ultrasound scanning in the detection of metastatic cervical lymph node involvement in patients with upper aerodigestive tract tumours. In particular, detection of carotid artery wall invasion by tumour was examined. Thirty-two neck dissection specimens were available for histopathological confirmation of findings. Palpation under general anaesthesia was 87.5% sensitive and 87.5% specific in the detection of involved nodes. If a positive finding was defined as detection of a node greater than 15 mm in largest diameter, CT scanning was 78.6% sensitive and 93.8% specific, and the sensitivity of ultrasound was 81.3% and specificity was 84.6%. Ultrasound scanning was sensitive in excluding carotid artery wall invasion, identifying five out of five cases with one false positive and no false negative reports. The combination of palpation under general anaesthesia and B-mode ultrasound imaging provides a sensitive means of detecting the presence of metastatic cervical lymphadenopathy and invasion of the carotid artery wall.